Information Collection

Main Study - Number to Complete the Screener

IC 232989 under ICR 201809-0910-003 · OMB 0910-0864.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A - Screener.docx	Other-Screener
Appendix B - Recruitment.docx Recruitment Materials	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener			Appendix A - Screener.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,525

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,525	3,525
Annual IC Time Burden (Hours)	106	106
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Materials	Appendix B - Recruitment.docx	09/12/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.